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rt"Ou. C,C <br /> STATEOFCAUFORWA <br /> STATE WATER RESOURCES CONTROL BOARD W nor <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE - <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT E�] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> p� _ r <br /> t <br /> ADDRIISNEARtSt dRdSS�Sf REST PAR EL ( A <br /> CITY NA STATE IP E SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ Box <br /> TOINDICATE CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' = FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RES✓ERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S' <br /> NI H AVE LAST,FIRS PH E#WIT E NIGHTS:#4AMIf(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR ST145ii 16REE418, box b Indicate INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE 21P CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> n <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> E�]CORPORATION O PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION (] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> l� Q LTM <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> ir i64 —1 <br /> !~ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1 OR MORt PERMIT APPLICATION- FORM B,UNLESS THIS M A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0013A-R7 <br />